A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

A 72-year-old adult is admitted to the hospital after several days of nausea, vomiting, and diarrhea. The nurse performs an assessment and reviews the client’s record. Which does the nurse conclude that the client is experiencing based on the data collected? Physical Assessment: Client reports muscle weakness and leg cramps Decreased bowel sounds, weak Irregular pulses Weight loss of 5 pounds LAB results: Serum potassium: 3.1 mEq/L Serum sodium: 138 mEq/L Serum magnesium: 2.2 mEq/L Serum calcium: 9 mg/dL Medications: Furosemide 40 mg, PO once daily in the morning Simvastatin 20 mg, PO at hour of sleep

The nurse is preparing to bathe the feet of a client with diabetes. Which action should the nurse take next?

A client with a new colostomy has been placed on a colostomy diet for the first 8 weeks following surgery. All of the following foods are acceptable for this diet except:

Dextrose 5% in water with dopamine is infusing at a rate of 102 mL per hour. The IV solution was prepared by adding 400 mg of dopamine to dextrose 5% in water. The final solution contained a total volume of 500 mL. How many mg are infusing per hour? How many mg are infusing per minute?

A nurse has several tasks to complete while preparing a client scheduled for surgery. Which of the following tasks can the nurse delegate to the unlicensed assistive personnel (UAP)?

The nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury?

An IV will be administered using an infusion pump that delivers mL per hour. Dextrose 5% in 0.45% sodium chloride has been prescribed to run IV at a rate of 21 mL per 2 hrs. The IV should infuse at how many mL per hour

A woman is in a car accident, and the hypothalmic-pituitary adrenal axis has triggered the fight-or-flight response. Which stage of General Adaptation is the woman exhibiting?